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ENHANCING THE ORIENTATION PROCESS FOR NURSE PRACTITIONERS ENTERING
PRIMARY CARE
A Dissertation
Submitted to the Graduate Faculty
of the
North Dakota State University
of Agriculture and Applied Science
By
Dustin Joel Czapiewski
In Partial Fulfillment of the Requirements
for the Degree of
DOCTOR OF NURSING PRACTICE
Major Department:
Nursing
April 2017
Fargo, North Dakota
North Dakota State University
Graduate School
Title
Enhancing the Orientation Process for Nurse Practitioners
Entering Primary Care
By
Dustin Joel Czapiewski
The Supervisory Committee certifies that this disquisition complies with North Dakota
State University’s regulations and meets the accepted standards for the degree of
DOCTOR OF NURSING PRACTICE
SUPERVISORY COMMITTEE:
Dr. Tina Lundeen
Chair
Dr. Adam Hohman
Dr. Leslie Koltes
Dr. Daniel Friesner
Approved:
5/1/2017 Dr. Carla Gross
Date Department Chair
iii
ABSTRACT
Novice nurse practitioners (NNPs) face many challenges when transitioning to practice,
which include, but are not limited to, time management, interprofessional relationships, role
ambiguity, transition shock, inconsistent onboarding, and lack of mentorship. The process of
transitioning from an experienced registered nurse (RN) to a NNP creates role ambiguity, self-
doubt, and feelings of inadequacy (Yeager, 2010). A structured orientation fosters a smoother
transition, increases role satisfaction and confidence. When healthcare organizations are able to
anticipate and minimize barriers, they increase the likelihood that NNPs experience a seamless
and successful transition.
The orientation process provides a roadmap for NNPs to navigate role acquisition,
develop interprofessional relationships, and enhance job satisfaction. A well-planned and
structured orientation should meet the needs of NNPs with and without familiarity with the
organization’s operations. Feedback obtained from NPs about the inconsistencies and deficits in
NP and PA provider orientation at the health care organization prompted evaluation, revision,
and re-structure of the orientation process. The purpose of this project was to evaluate the
orientation process at a healthcare institution. Using a plan-do-study-act (PDSA) model the
orientation process was evaluated, barriers identified, and recommendations made to the
organization. Two cohorts of NNPs were interviewed. Cohort 1 worked at the healthcare
organization for 12-18 months, while Cohort 2 worked at the healthcare organization for 1-5
months. Both cohorts had the same general orientation; however, Cohort 2 had a more
structured clinical orientation.
iv
Through the interviews, major themes emerged, and then categorized into the following:
general-provider orientation, clinical orientation, clinical competencies, and electronic medical
record (EMR). NNPs requested a more structured orientation process, wanted a designated
preceptor or mentor, needed guidance on skill validation, and preferred individualized EMR
education. Limitations include a small sample size, an inconsistent interview process, and
variable orientation processes in the cohorts. There is a need for further research to identify best
practices to improve and nurture the transition of the NNP to an expert nurse practitioner (NP).
Outcome studies are needed that focus on how NNPs successful transition effects quality of
patient care.
v
ACKNOWLEDGEMENTS
I would like to acknowledge and extend my gratitude to my committee members: Dr.
Lundeen, Dr. Hohman, Dr. Koltes, and Dr. Friesner. A special thank you goes to Dr. Lundeen
for inspiring me to explore a topic that is integral to the professional development of many nurse
practitioners as they transition to practice. This project has introduced me to the challenges that
nurse practitioners face during their entry into practice even though nurse practitioners have been
a valuable part of the healthcare team for over 60 years.
The healthcare organization’s leadership team, which included Dr. Lundeen,
demonstrated the value of leadership. The leadership team expressed the value and importance
of developing an orientation process in primary care to meet the needs of the NNP as they enter
practice. The leadership teams across many sections of the organization showed me that
investing in those we serve is not only valuable to the organization, but also to the people, it
serves. The organization’s leadership team and the advanced practice leadership group has,
identified a lack of an orientation process for NNPs in primary care, and aspired to create an
efficient and effective orientation process to aid the NNPs’ transition to practice.
Last, I would like to acknowledge the support that I have received from my family during
this journey. My family has supported me by helping me with daily tasks. I would especially
like to thank my wife, Jamie Czapiewski. She has been there day in and day out, supporting me
to accomplish my goals and dreams. Her reassuring support gave me motivation during the
tough times, and helped me to remember the accomplishments that I had achieved during this
journey.
vi
TABLE OF CONTENTS
ABSTRACT ................................................................................................................................... iii
ACKNOWLEDGEMENTS ............................................................................................................ v
LIST OF FIGURES ....................................................................................................................... ix
CHAPTER ONE. INTRODUCTION ............................................................................................. 1
Problem Statement ...................................................................................................................... 1
Purpose ........................................................................................................................................ 5
CHAPTER TWO. LITERATURE REVIEW OF EVIDENCE-BASED PRACTICE ................... 8
CHAPTER THREE. THEORETICAL FRAMEWORK .............................................................. 12
From Novice to Expert .............................................................................................................. 12
CHAPTER FOUR. PROJECT DESIGN ...................................................................................... 16
Introduction ............................................................................................................................... 16
Plan-Do-Study-Act Model ........................................................................................................ 16
Plan ........................................................................................................................................ 17
Do .......................................................................................................................................... 21
Study ...................................................................................................................................... 23
Act ......................................................................................................................................... 23
Project Resources ...................................................................................................................... 23
Protection of Human Subjects ................................................................................................... 24
Program Objectives ................................................................................................................... 25
CHAPTER FIVE. RESULTS ....................................................................................................... 26
Demographics ............................................................................................................................ 26
Cohort 1 ................................................................................................................................. 26
Cohort 2 ................................................................................................................................. 26
General-Provider Orientation .................................................................................................... 27
vii
Cohort 1 ................................................................................................................................. 27
Cohort 2 ................................................................................................................................. 27
Clinic Orientation ...................................................................................................................... 28
Cohort 1 ................................................................................................................................. 28
Cohort 2 ................................................................................................................................. 30
Clinical Competencies ............................................................................................................... 31
Cohort 1 ................................................................................................................................. 33
Cohort 2 ................................................................................................................................. 34
Electronic Medical Record ........................................................................................................ 35
Cohort 1 ................................................................................................................................. 35
Cohort 2 ................................................................................................................................. 35
CHAPTER SIX. DISCUSSION AND CONCLUSION ............................................................... 37
General-Provider Orientation .................................................................................................... 38
Clinic Orientation ...................................................................................................................... 39
Clinical Competencies ............................................................................................................... 42
Electronic Medical Record ........................................................................................................ 43
Limitations ................................................................................................................................ 44
Recommendations ..................................................................................................................... 46
Implication for Practice ............................................................................................................. 48
Conclusion ................................................................................................................................. 50
REFERENCES ............................................................................................................................. 51
APPENDIX A. PERMISSION TO USE BENNER’S “NOVICE TO EXPERT” NURSING
THEORY IMAGE ........................................................................................................................ 56
APPENDIX B. PERMISSION TO USE THE REPEATED PDSA CYCLE ............................... 58
APPENDIX C. NDSU IRB APPROVAL .................................................................................... 59
APPENDIX D. GENERAL-PROVIDER ORIENTATION SAMPLE SCHEDULE .................. 60
viii
APPENDIX E. STRUCTURED ORIENTATION PROCESS ..................................................... 61
APPENDIX F. NOVICE NURSE PRACTITIONER INTERVIEW QUESTIONAIRE ............. 64
APPENDIX G. EMAILED INVITATION AND INFORMED CONSENT................................ 66
APPENDIX H. EXECUTIVE SUMMARY ................................................................................. 69
Background and Significance .................................................................................................... 69
Project Summary ....................................................................................................................... 69
Common Themes ...................................................................................................................... 70
General-Provider Orientation ................................................................................................ 70
Clinic Orientation .................................................................................................................. 70
Clinical Competencies ........................................................................................................... 73
Electronic Medical Record .................................................................................................... 74
Recommendations ..................................................................................................................... 75
ix
LIST OF FIGURES
Figures Page
1. From Novice to Expert Theory (Vanderbilt Center for Teaching, n.d.) ................................... 13
2. PDSA model (Tribal Evaluation Institute, n.d.) ....................................................................... 17
3. PCQMs identified by participants ............................................................................................. 35
1
CHAPTER ONE. INTRODUCTION
The utilization of novice nurse practitioners (NNPs) in primary care is crucial to meet the
United States’ healthcare needs. In March 2010, the U.S. Congress passed the Patient Protection
and Affordable Care Act (PPACA) expanding Medicaid and improving access to healthcare for
nearly 40 million Americans and healthcare insurance for more than 30 million previously
uninsured Americans (Aston, 2011; Owens, 2012; Pericak, 2011). The influx of people having
access to healthcare, along with an aging and growing population, is creating an increased
demand for primary-care providers (PCP). Nearly half of all patients seen in primary care
present with chronic conditions, including hypertension, hyperlipidemia, diabetes mellitus,
depression, obesity, arthritis, asthma, and chronic obstructive pulmonary disease (Hooker &
Everett, 2011).
Problem Statement
Transitioning from a competent or experienced RN to a NNP is challenging. Sullivan-
Bentz et al. (2010) reported that the first year of transition is difficult for NNPs due to the
complex and demanding expectations of practice. During this period, the NNPs lay the
groundwork to develop their practice, to expand upon their knowledge, and to advance their
clinical expertise while struggling to survive in a demanding healthcare system (Hill &
Sawatzky, 2011). NNPs experience difficulty with role identification as they transition from a
nurse to a provider (Fitzpatrick & Gripshover, 2016). During role transition, NNPs blame
themselves for uncertainty, slowness, scheduling problems, and system issues due to lack of
experience. NNPs require more time for conducting exams, documenting patient visits,
reviewing charts, interpreting laboratory values, learning the referral process, and requesting
consults (Hill & Sawatzky, 2011).
2
According to Barnes (2015a), the NNP shifts from being an experienced and competent
RN to an inexperienced, less confident NNP. The literature is sparse about how the amount and
type of RN experience affects role transition. Barnes (2015a) concluded that a formal orientation
was more important for successful transition than was RN experience or the level of graduate
education. Many NNPs feel that they need to be fully competent and knowledgeable about all
aspects of their role after graduation (Hill & Sawatzky, 2011). NNPs believe that they need to be
experts in advanced diagnostic skills, critical-thinking abilities, pharmacological therapy, and
disease treatment in order to be a value to the healthcare team (Hill & Sawatzky, 2011). In order
to obtain their peers’ respect, NNPs think that they need to practice independently when
managing their patients (Hill & Sawatzky, 2011). Feelings of inadequacy and self-doubt lead
NNPs to experience an imposter syndrome in the clinical setting. Imposter syndrome is a
phenomenon used to describe the internal thoughts of self-doubt and feelings of intellectual
fraudulence, leading to anxiety, a lack of self-confidence, depression, and frustration, resulting in
the inability to meet their self-imposed standards during their transition to practice (Yeager,
2010).
According to Fitzpatrick & Gripshover (2016), NNPs experience a phenomenon they
term transition shock. The term, transition shock, was defined by the authors as feelings of
“disorientation, confusion, and doubt-ridden chaos” (p. 419) that occurs during the transition
from the academic setting to the practice setting. Transition shock can trigger a host of negative
feelings in the NNP and may lead to role frustration, mediocre performance, and in some
instances, unsuccessful transition, and workplace failure. Ongoing support and guidance from
administration and colleagues can ease transition shock, and can have a positive effect on the job
satisfaction, care quality, and retention rates of NNPs (Fitzpatrick & Gripshover, 2016).
3
Kelly and Mathews (2001) found that many NNPs felt a loss of control about their time.
In addition, Hill and Sawatzky (2011) found that many NNPs were working longer hours with
fewer breaks, leading to exhaustion, isolation, and despair. The isolation and despair increases
as the NNP experiences intense scrutiny during their transition to practice. As a result, anxiety,
insecurity, and exhaustion cause many NNPs to experience role dissatisfaction, suboptimal
performance, and a failure in the workplace (Fitzpatrick & Gripshover, 2016). Understanding
and identifying the challenges facing NNPs during their transition to practice may eliminate the
anguish and loss of time control experienced by many NNPs.
NNPs face many challenges when practicing in primary care. The intense scrutiny
towards the NNP occurs due to clinical team members frequently testing the NNPs ability to
provide care (Yeager, 2010). Support received from the clinical team and the healthcare
organization’s leadership is essential for the development of an NNP’s role identification
(Fitzpatrick & Gripshover, 2016). The scrutiny, coupled with returning to the uncomfortable
novice phase, increases the likelihood that the NNP will experience self-doubt and feelings of
inadequacy (Yeager, 2010). The lack of self-confidence results in second guessing correct
interventions, leading to a constant state of fear about overlooking or missing something (Hill &
Sawatzky, 2011).
New providers have reported dissatisfaction with interprofessional relationships and a
lack of support (Yeager, 2010). NNPs do not receive the same level of support as physicians
delivering similar care, which influences the relationships they have with physicians,
administrators, and other staff members. Nurse practitioners (NPs) and physicians view their
relationship as supervisory, rather than collaborative (Poghosyan et al., 2012). Physicians’
unfamiliarity with the NP scope of practice limits NNP role development and scope of practice.
4
When limitations are place on NPs they are not able to practice to the full extent of their
education and training (Institute of Medicine, 2015). Decades of research show NPs provide safe
and effective care while playing an integral role in the healthcare team.
Transition shock, role ambiguity, and role dissatisfaction have contributed to job turnover
rates for NNPs that are almost double the turnover rate of physicians’ (Fitzpatrick & Gripshover,
2016). A 2011 physician retention survey by Cejka and the American Medical Group
Association (AMA), reported a turnover rate for NNPs as 12.6% in the first year (Schwartz,
2013). Low retention rates are costly for the healthcare organization. The estimated cost of an
NP position that is open for 3 months costs $89,000 (Schwartz, 2013). According to The Robert
Wood Johnson Foundation, the cost to replace a healthcare provider ranged from 20% of annual
salary, to hundreds of thousands of dollars (Blake, 2015). Healthcare organizations with low
turnover rates save a mean of $3.6 million per year on overall costs compared to healthcare
organizations with higher turnover rates (Dillon, Dolansky, Casey, & Kelley, 2016). Removing
the barriers to professional autonomy will decrease turnover rates, increase job satisfaction, and
improve role identification.
Several organizations, including the Commission on Collegiate Nursing Education
(CCNE), the National Organization of Nurse Practitioner Faculty (NONPF), and the Institute of
Medicine (IOM), have convened panels to evaluate the best way to bridge the gap between
education and practice. Traditionally, the employer assumed the responsibility for oversight and
supervision of the NNP’s transition from student to provider. Employers typically use an
orientation process as a method to introduce the NNP to practice. The amount of orientation
time, as well as what is included in orientation, differs from organization to organization, and
often differs from department to department within the same organization. A well-planned,
5
structured orientation process should be designed to do more than orientate the NNP to the
organization. A structured orientation should be designed to bridge the education to practice
chasm by providing the tools and resources necessary for a successful transition. The IOM
(2015) has recommended the development of NP fellowship or residency programs as a strategy
to supplement or replace orientation, ease role transition, and promote the hiring and retention of
skilled providers. Each year the number of NPs graduating and entering the workforce is rising
(American Association of Nurse Practitioners [AANP], 2015). Over 20,000 NPs completed their
education in 2015, of those 87% graduated from primary care programs (Pohl, Thomas,
Barksdale, & Werner, 2016). Educators and healthcare leaders, with input from NNPs, should
collectively design an evidence based comprehensive orientation program to effectively
transition the large number of NNPs entering practice.
Purpose
The groundwork for evaluating the healthcare organizations structured orientation
process focused on the NNPs’ role, transition to practice, barriers to NNPs’ transition to practice,
and interventions to remove the barriers during their transition to practice. Understanding how
the NNP fits into the organization takes time and experience which is difficult due to factors such
as understanding the workplace functions, health professionals’ role, where people fit within the
organization, and how they get simple and complex tasks accomplished (Hill & Sawatzky,
2011). Hill and Sawatzky (2011) concluded that role ambiguity was a common barrier
encountered by NNPs because their function and scope of practice differed slightly depending on
the employment site and the available opportunities. The NNP seeks clarity and understanding
of a role that is “neither nurse nor physician” causing frustration and confusion for NNPs as they
learn how their role fits within the organization (Faraz, 2017a p. 28; Hill & Sawatzky, 2011).
6
Additionally, healthcare organizations, physicians, nurses, allied health professionals, and the
public may lack understanding about the NP role. The progression from role ambiguity to role
acquisition can be fostered by clearly defining the NNPs professional responsibilities within the
organization (Hill & Sawatzky, 2011).
Approximately 70-80% of NPs graduating choose to work in primary care (Naylor and
Kurtzman, 2010). NNPs provide a sustainable supply of PCPs, thus increasing patients’ access
to care, especially in rural and underserved areas. Enrollment and graduation rates for NNPs
have consistently increased over the past several years, enhancing the growing percentage of
NNPs trained to provide primary care (Nurse Practitioners in Primary Care, 2016). NNPs are
prepared through master or doctoral graduate program that integrate didactic and clinical courses
to prepare graduates with the knowledge and competencies needed to become advanced practice
nurse (Nurse Practitioners in Primary Care, 2016). The NNPs’ scope of practice includes
blending nursing with medical services to diagnose and to manage acute and chronic conditions
through health promotion and disease prevention (Nurse Practitioners in Primary Care, 2016).
NNPs have proven their cost effectiveness within the healthcare system by providing high-
quality care and high patient satisfaction while reducing the cost of healthcare (Bauer, 2010;
Nurse Practitioners in Primary Care, 2016; Poghosyan et al., 2014). By 2025, the NNP
workforce is projected to grow by 130%, which means the addition of more than 250,000 NNPs
(Poghosyan, Boyd, & Knutson, 2014; Poghosyan, Lucero, Rauch, & Berkowitz, 2012). The
exponential growth projected for a highly qualified and valuable healthcare provider, requires the
attention of the healthcare organizations. Healthcare organization need to develop, implement,
and study orientations leading to NNPs’ successful transition to practice.
7
An estimated 20,000 NPs graduated and entered the workforce in 2014-2015 (Pohl,
Thomas, Barksdale, & Werner, 2016). Research about NP transition to practice has exploded in
the last few years, as an effort to meet the demands of the large influx of NPs into the work
force. What are the best methods to ease transition from academia to practice in the real world?
The focus has gravitated to residency and fellowship programs as a method transition NNPs to
practice. Developing, funding, and finding fellowship or residency programs for 20,000 NNPs
per year is unrealistic. At most healthcare organizations, the orientation process serves as the
identified method for NPs to transition to their new role. The goal of this project was to compare
and evaluate the previous and current orientation process by interviewing NNPs who went
through the previous orientation (Cohort 1) and the most recent orientation (Cohort 2) at one
healthcare organization.
8
CHAPTER TWO. LITERATURE REVIEW OF EVIDENCE-BASED PRACTICE
The literature review focused on two main themes: role transition, and orientation of new
nurse practitioners. The literature search on NNP orientation was focused on best practices,
structure, and evaluation. Search topics included fostering role development, transition to
practice, transition barriers, and interventions to eliminate the transition to practice barriers for
newly graduated nurse practitioners. Data obtained from the Cumulative Index to Nursing and
Allied Health Literature (CINAHL) Complete, Medical Literature Analysis and Retrieval System
Online (MEDLINE), and Health Source databases from 2005-2017 established the foundation
for evaluating the structured orientation process. The key terms used to complete the search
were mentor, nurse practitioner, physician assistant, role transition, orientation, and primary care.
Inclusion criteria included 1,012 articles written from 2005-2017 and available in full text in the
English language. The titles and abstracts were reviewed for applicability to the project.
Very few articles discussed the orientation process for NNPs in primary care, with much
of the research focusing on mentorship programs, residency programs, and orientation to
specialty care. Given the lack of research, healthcare organizations are attempting to define best
practices through “trial and error.” As healthcare organizations discover effective ways to
orientate most NNPs, they should be encouraged to publish and disseminate their results.
The research on issues related to transition to practice has exploded over the past several
years. Faraz (2016b) performed an integrative review on the novice nurse practitioner transition
in primary care. Faraz’s review of the literature was categorized into three common themes:
experiencing role ambiguity, quality of professional and interprofessional relationships, and
facing intrinsic and extrinsic obstacles. NNPs, NP employers, and NP educators all have a role
9
in the development of strategies that reduce NP role ambiguity, improve intra-professional
relationships, and reduce the barriers to successful transition.
The orientation process is the first step into a new role and/or organization after
graduation. Orientation provides a roadmap for new employees to navigate and to develop
throughout their career. A comprehensive orientation process should include a system-wide
orientation along with a job-specific orientation. The system-wide orientation should include the
organization and system’s policies, informatics, computer-order entry, procedural training
sessions, safety, equipment training, employee-identification badge process, office access,
completing credentialing packets, and setting up voicemail (Yeager, 2010). Job-specific
orientation needs to include education about how to access patient records, enter orders, access
dictation lines, retrieve radiographic studies, build relationships, observe clinical flow, and
acquire procedural skills (Yeager, 2010).
One of the IOM recommendations in their follow-up report to The Future of Nursing,
Leading Change and Advancing Health, was to create and fund transition to practice residency
programs (Institute of Medicine, 2015). There has been a significant increase in research on
residency programs post-graduation as a means to improve the NNPs transition to practice.
Residency programs were developed to facilitate a successful transition to practice by offering a
six to twelve-month transition between didactics and clinical competency during the initial year
of practice (Fitzgerald, 2015). Residency programs place the NNP in the clinical setting, while
incorporating didactic learning in several different formats (Harris, 2014). Residency programs
provide mentorship and specialty training for the NNP, and a way to recruit and retain new hires
(Harris, 2014). NNPs who took part in residency programs reported an easier transition to
practice, an enhancement of clinical skills, a greater understanding about the role of all health
10
professionals on the team, and a commitment to interprofessional teamwork (Zapatka, Conelius,
Edwards, Meyer, & Brienza, 2014).
While residency programs have shown success, the programs have failed to escalate in
popularity due to lack of funding. The cost of the NNP not practicing independently, coupled
with increased cost of overhead, administrative resources, and educational resources limits
healthcare organization fiscal ability to implement residency programs for NNPs (Harris, 2014).
Unfortunately, federal funding is not available which forces healthcare organizations to fund the
programs through internal resources (Harris, 2014). Many organizations pay resident NPs a
reduced salary up to 75% of now practicing NPs (Harris, 2014).
Mentorship programs provide another choice for healthcare organizations to facilitate the
NNPs’ transition to practice. Mentoring is a relationship between a novice and an expert for the
purpose of role socialization and role success (Hill & Sawatzky, 2011). Mentorship programs
provide the opportunity for a mentor to challenge, advise, guide, and counsel NNPs during their
transition into practice (Harrington, 2011; Fitzpatrick & Gripshover, 2016). Hill & Sawatzky
(2011) found that mentoring reduced the internal and external stressors and anxiety NNPs
experience during their first year of practice. The authors also suggested that mentorship
programs offer an opportunity for NNPs to develop tacit knowledge to fill the gap between
didactic information and real world experiences (Hill & Sawatzky, 2011). Tacit knowledge
develops from personal experience, intuition, judgment, knowledge, expertise, and individual
insight (Tourigny & Pulich, 2005).
Although the healthcare organization, the mentors, and the mentees reap benefits from a
successful mentoring program, they also face several barriers that could affect the mentoring
experience. Common barriers for organizations include cost, time factors, scheduling
11
limitations, and space constraints (Harrington, 2011). Mentors’ and mentees’ barriers may
include, competing demands on their time, differing personalities, attaining education on the
mentoring process, lacking organizational support, and unfulfilling patient needs.
12
CHAPTER THREE. THEORETICAL FRAMEWORK
From Novice to Expert
Patrician Benner’s From Novice to Expert middle-range nursing theory helps to
understand the perceptions of NNPs during their transition from an expert nurse to a novice NP.
Benner did not specifically evaluate the RN to NP transition; however, her new-to-expert
framework can be easily extrapolated to similar professional transitions. In 1982, Benner
transformed Dreyfus’ model of skill acquisition to meet the demands for nursing in the acute-
care setting (Benner, 1982). Dreyfus’ model of skill acquisition focused on skill performance
that is based on experience and education. The complexity of nursing care in the acute-care
setting prevented nursing from being standardized, routinized, and delegated. Benner’s career
development theory suggests that the road to expert status requires experience, time, and a
lifelong commitment to career development (Benner, 1982).
Benner’s theory provides a basis for clinical knowledge development and career
progression as the nurse goes through the five proficiency levels. The five levels of proficiency
are novice, beginner, competent, proficient, and expert (Figure 1). Each level reflects a change
from reliance on abstract principles to the use of past, concrete experiences as paradigms.
Certain parts of a situation are relevant as the nurse’s perception and understanding about a
situation expand to see the complete whole (Benner, 1982).
13
Figure 1. From Novice to Expert Theory (Vanderbilt Center for Teaching, n.d.). Reprinted with
permission from Mr. Richard Cobles. Religion, Psychology and Culture Graduand Theology and
Practice Fellow, and Rhett McDaniel, Educational Technologist, at Vanderbilt’s Center for
Teaching (Appendix A). The image above illustrates Benner’s “Novice to Expert” nursing
theory and the components within each stage.
A new NNP enters practice as a novice with no situational experiences, and uses
objective attributes to form his/her clinical decisions (Benner, 1982). The lack of experience
caused novices to follow rules that they learned in the past to guide their actions for new
situations (Benner, 1982).
Once the novice has shown a marginally acceptable performance, he/she enters the
beginner stage. The beginner has enough experience to find meaningful situational components
but fails to embrace the situation. Since the situation is new, the beginner relies on remembered
rules and general guidelines (Benner, 1982).
14
The beginner becomes competent once he/she develops the capability to envision long-
term goals and to prioritize interventions for patient care. Competent providers experience a
feeling of mastery with the ability to cope and manage clinical situations (Benner, 1982).
Although competent nurses understand the situation, they lack the speed and flexibility of a
proficient provider.
A proficient provider sees the situation as a whole rather than parts. Proficient providers
anticipate typical events for a situation and modify their plans in response to the events based on
their experiences (Benner, 1982). Compared to a competent provider, proficient providers
recognize abnormal presentations and implement interventions that are more precise (Benner,
1982).
Expert providers have an intuitive grasp of the situation, and have the ability to focus on
the problem without wasteful interventions (Benner, 1982). Expert providers use their
experience instead of the rules or guidelines to connect their understanding of the situation to an
intervention (Benner, 1982).
Benner’s novice to expert theory offers an understanding about the role transition that
RNs experience during his/her new role as a provider. Many NP programs do not incorporate a
defined level of experience that is required for admission to the program, allowing for a wide
range of RN experiences. Each RN enters the NP program with his/her clinical experience from
a vast array of clinical settings, leading to a diversity of clinical competence within each
program. No matter what level the new NP’s clinical background is as a RN, all new NPs enter
as a novice. This practice-improvement project (PIP) was designed to evaluate the effect of a
structured orientation process on the NNP’s transition to practice based on Benner’s novice to
expert nursing theory. In conjunction with Benner’s Theory, the plan-do-study-act (PDSA)
15
model provides an appropriate theoretical framework and project model for continual evaluation
of the orientation process for the healthcare organization, which is discussed in Chapter 4.
16
CHAPTER FOUR. PROJECT DESIGN
Introduction
The initial intent of the PIP was to develop, implement, and evaluate, an orientation
process for new NP and PA providers starting employment at a healthcare organization.
Advance practice leaders at the target healthcare organization requested assistance in improving
the orientation process for new providers. The leaders had received unsolicited feedback from
NNP and PA employees about the inconsistencies and lack of structure of their orientation
process. The orientation process differed from clinic to clinic, department to department, and
provider to provider. The advanced practice leadership group’s intent was the creation of a
comprehensive, structured, and consistent orientation for NPs and PAs hired to work in primary
care. The initial objective of this PIP was to assist in the development, implementation, and
evaluation of an orientation program. The focus of the PIP changed when administrators at the
healthcare organization implemented a separate structured orientation process. The focus of the
PIP shifted to assisting the healthcare organization and the advanced practice leaders to compare
and evaluate the previous and current orientation process by interviewing NNPs who went
through the previous orientation (Cohort 1) and the most recent orientation (Cohort 2). The
orientation process was evaluated using the PDSA model.
Plan-Do-Study-Act Model
The orientation process is a dynamic and fluid activity that considers the NNPs’ needs.
The PIP was structured using the PDSA model in conjunction with Benner’s novice to expert
nursing theory. Other names for the PDSA are rapid-cycle improvement, plan-do-check-act
(PDCA), and the Shewhart cycle (Taylor et al., 2013). The PDSA utilizes the scientific method
of hypothesis – experiment – evaluation (Taylor et al., 2013).
17
The PDSA model was useful in planning, implementing, and evaluating the change in
orientation. A successful orientation process needs to be adaptable to the participants and
organization’s changing needs. To ensure success, the orientation process should have a
foundation that utilizes a model, which can continually adapt and adjust. The PDSA model
(Figure 2) is a cyclic model designed for the dynamic and fluent process needed for the
development of a successful structured orientation process.
Figure 2. PDSA model (Tribal Evaluation Institute, n.d.). Reprinted with permission from the
Tribal Evaluation Institute (Appendix B). The image above illustrates the PDSA cycle and its
components.
Plan
As previously mentioned, the PIP changed when a new, structured orientation process
was implemented within the organization. The structured orientation standardized the
orientation process across all primary care clinics and departments. Non-structured orientations
found throughout primary care included no clinical orientation, becoming a scribe for another
provider, and an opportunity to shadow another provider, which is discussed in further detail in
Chapter 5.
18
The planning stage involved development of the project steps, identification of
stakeholders, approval of NDSU dissertation committee, approval from the healthcare
organization’s student project committee, Institutional Review Board (IRB)approval, and
identification of the sample. Stakeholders included the organization’s advanced-practice
provider leadership, student project committee, a representative from the education department,
and eligible sample of NNPs.
The goal of the PIP was to assess the perceived effectiveness of the structured orientation
process for NNPs working in primary care at a healthcare organization located in the Midwest
United States. The eligible sample included NNPs starting employment in family medicine or
internal medicine from January 2015 to November 2016. NNPs who were transferring from one
primary care setting to another, practicing in a specialty areas, outlying facilities, and rural
clinics were excluded from the project. NNPs were separated into two cohorts and individual
interviews were scheduled and conducted with each participant in the cohorts. Cohort 1 included
participants who were not involved with a structured orientation process at the healthcare
organization, and entered practice during January 2015 to June 2016. Cohort 2 included
participants who took part in the structured orientation process at the same healthcare
organization, and entered practice during July 2016 to November 2016.
Interviews were conducted with participants face-to-face, which was the preferred
interaction, or by email at the request of the participants. After the interviews, data was analyzed
for perceived barriers and benefits of the unstructured orientation of Cohort 1 and the structured
orientation process experienced by Cohort 2. The literature review, collective data, and themes
from the participant interviews, recommendations for improvement, and areas of best practice
would be shared with the healthcare organization.
19
The healthcare organization’s structured orientation process (Appendix E) is a four-phase
process that lasts a minimum of 4 weeks, with the goal of completing the orientation process
within 8 weeks.
Phase 1: General Orientation. Phase 1 (Appendix D) is a three-day meeting is
designed for all the organization’s new providers. At the general orientation, the providers
receive a detailed itinerary that identifies the presenters and topics that are covered throughout
the general orientation. The presenters and topics focus on providing information about the
organization and introducing the healthcare organization’s leadership team. In addition, the NNP
is shown the process of creating smart phrases, which are preformatted phrases and statements of
data or text to facilitate documentation and patient education in the electronic medical record
(EMR).
Phase 2: Department Orientation. Phase 2 starts on day four and concludes at the end
on week two. Phase 2 focuses on a department-specific orientation. The clinical supervisor
assigns the NNP to a designated provider who will be the preceptor throughout the departmental
orientation. Phase 2 includes the following:
• Tour of the clinic.
• Introduction to the clinic director, clinical supervisor, and other team members.
• Introduction to the scheduling template.
• Review of workflow and department policies.
• Development of individual documentation templates and smart phrases in the EMR.
20
Phase 3: Begin Concurrent Visits. Phase 3 starts on week three and concludes within 1
to 6 weeks, depending on the progression of the NNP. The structure of each week is as follows:
• Week 1.
o Perform and document the entire patient visit with the preceptor’s direct
supervision.
• Week 2.
o 60-minute patient visits scheduled.
o Contact clinic’s EMR trainer to schedule training session during week 3.
o Discuss with preceptor to consider starting 45-minute appointments during
week 3.
• Week 3.
o May include hospital rounds/visits if they are part of the NNP’s job duties.
o Perform and document hospital rounds/visits under the preceptor’s direct
supervision.
o Repeat week 2 if clinic does not participate in hospital rounds/visits.
• Week 4 and 5.
o Discuss with preceptor to consider starting 30-minute appointment during
weeks 5/6.
• Week 6.
o Schedule most appointments for 30-minutes.
o Discuss with preceptor about increasing patient schedule to 75% of an
established provider’s patient schedule for the following week.
21
Phase 4: Conclusion of Orientation. In Phase 4, the NNP is routinely seeing 75% of an
established provider’s patient schedule. Most NNPs are expected to complete Phase 4 by the end
of week 8 in collaboration and agreement with the clinical team and NNP. After completing
Phase 4, the NNP will gradually increase the number of patients seen per day based on his/her
comfort level and efficiency, until their patient schedule reaches the threshold of an established
provider. The NNP has scheduled appointments with a variety of team members throughout the
orientation and after completion of orientation, which are as follows:
• Director or clinical supervisor during weeks 4 and 8.
• Coding specialist during weeks 8 and 12.
• Department chair or vice president during week 12.
• Department leadership quarterly for the first year of practice.
Do
IRB approval was obtained from NDSU and IRB exemption was received from the
healthcare organization. After the organization implemented their new orientation for NNPs, the
“do” stage was entered. The director of the education department identified potential
participants based on the NNPs start date. Potential participants were contacted via e-mail, with
the purpose of introducing the project and asking for participation in the project. Cohort 1
included six potential participants, and Cohort 2 included four potential participants. Cohort 1
included all six NNPs who were hired in internal medicine or family medicine between January
2015 and June 2016. Cohort 1 did not have a formal orientation and the quality and extent of
orientation varied from participant to participant. Cohort 2 included three NNPs who were hired
in internal medicine or family medicine between July 2016 and November 2016. This cohort
took part in the structured orientation process, which was the focus of the PIP. Data collection
22
began by obtaining information from participants about their perceptions of the orientation
process that they completed during their transition to practice. Cohort 1’s data collection started
immediately after attaining the IRB approval while Cohort 2’s data collection began after the
participants were practicing independently for at least two weeks.
The study questionnaire, Novice Nurse Practitioner Interview Questionnaire (Appendix
F), facilitated the data that was collected from the participants involved with the PIP. The data
obtained included participants’ demographics, general-provider orientation, clinical orientation,
questions about their practice pre- and post-orientation, preceptor experience, interprofessional
relationships, and educational preparation. The data collection occurred via face-to-face
interviews and an e-mail questionaire with telephone communication to decipher ambiguous
data. All Cohort 1 participants agreed to a face-to-face interview. While all Cohort 2
participants declined to participate in a face-to-face or telephone interviews, citing a lack of time,
but were willing to complete the interview questionnaire through email and be available for
clarification answers through telephone conversations. The e-mail questionaire was sent to
Cohort 2 utilizing the questions asked during the face-to-face interviews. Each participant
received a $20 Visa gift card for his/her participation in the PIP.
23
Study
The “study” stage started when all data was collected and analyzed from Cohorts 1 and 2.
During this data analysis, the project assessed the barriers facing NNPs who were practicing in
primary care. The project assessed for any unintended adverse effects and created a foundation
for further pilot projects. Data obtained from Cohorts 1 and 2 was categorized by common
themes. The themes are as follows:
• General-Provider Orientation
• Clinical Orientation
• Clinical Competencies
• Electronic Medical Record
Act
After data collection, the “act” stage started when creating recommendations for the
structured orientation process. The PIP evaluated the effectiveness of the structured orientation
process to facilitate the NNPs’ transition to practice. The PIP addressed any adverse effects and
provided recommendations for further enhancing the NNPs’ orientation process at the healthcare
organization. The stakeholders involved with the PIP’s development and implementation
received the results and recommendations from implementing the PIP.
Project Resources
The resources needed to implement the PIP were NNPs, physicians, EMR trainers,
human-resource personnel, and ancillary staff in the clinic setting. The PIP team members
dedicated seven months of time for the completion and evaluation of data obtained from the two
cohorts.
24
Protection of Human Subjects
NDSU granted Institutional Review Board (IRB) approval (Appendix C) on May 25,
2016. The healthcare organization provided exemption of the PIP from IRB approval on
September 12, 2016 because the activity was not human research. The initial process for the
protection of human subjects began with the submission of a PIP proposal to the IRB at NDSU.
The NDSU IRB categorized the project as exempt category one: the research conducted and
established, or commonly accepted educational setting involving normal educational practices.
The PIP had minimal-to-no risk of harm to subjects, involved no procedures, and involved no
direct patient contact making the project a clinical-improvement project and not a human-subject
research project. All participants who volunteered for this practice-improvement project were
greater than 18 years of age and received an email containing relevant information necessary to
giving informed consent (Appendix G).
The data obtained was kept confidential and reported in a manner that participants could
not be identified. The participants were informed that they could withdraw from the project at
any time. Participant permission was obtained to audio record the interview. Audio recordings
ensured the notes recorded during the interview correlated with what the participants said to
ensure data accuracy. The participants were assured that confidentiality would be kept at the
highest level with the recording device and notes being safeguarded at the author’s home while
not in use. Data obtained through telephone conversations was not recorded, and closed loop
communication was used to ensure data accuracy. Data obtained from e-mails were sent and
received from one private server. The e-mailed questionnaire results were printed without
identifying data, secured in the same location as the recordings, and deleted at once from the
server.
25
Program Objectives
The objectives for the PIP include:
1. Interview primary care NNPs to identify the barriers experienced during role transition
and entry to practice. The interview questionnaire focused on the topics of orientation,
mentoring, and support.
2. Evaluate NNPs perceptions of orientation using the plan-do-study-act model.
3. Analyze feedback from two cohorts of NNPs about the previous and current orientation
program, and provide recommendations to the healthcare organization.
26
CHAPTER FIVE. RESULTS
Data was collected over a seven-month period, incorporating the time needed for the
healthcare organization to create a committee to assess PIPs and scheduling the data-collection
time with the participants. Data from Cohort 1 participants were obtained through face-to-face
interviews. Data from Cohort 2 participants were obtained with the participant completing the
Novice Nurse Practitioner Interview Questionnaire (Appendix F) online due to the inability to
schedule interviews. The participants completing the Novice Nurse Practitioner Interview
Questionnaire gave some ambiguous answer leading for the NNPs to clarified their answers
through telephone communications.
Demographics
Cohort 1
The six participants in Cohort 1 had similar educational preparation and clinical
experience as a NNP. Participants in Cohort 1 had between 8 and 16 months of clinical
experience, with a mean of 12.6 months. Four participants practiced in family medicine while
the remaining two participants practiced in internal medicine. Three participants were new to the
organization however; none of the participants had previously worked in their clinic where they
were practicing. Five of the six participants were female, ages ranged from 28 years to 51 years
of age (mean of 35.5 years of age). All participants were employed full time, maintaining a full-
time equivalent (FTE) of 0.8 or greater.
Cohort 2
The three participants in Cohort 2 had similar clinical experience as an NNP. The NNPs
had 1 to 5 months of clinical experience at the time of interview. One participant practiced in
family medicine and two participants practiced in internal medicine. Participants had been
27
employed as an RN at the organization prior to being hired as an NP. However, just one
participant had previously worked in the same clinical area within the organization. All
participants were female, worked full time status of 0.8 FTE or greater, with ages range from 27
to 39 years of age (mean of 32 years of age).
General-Provider Orientation
The general-provider orientation (Appendix D), Phase 1 of the structured orientation
process, was included in all participant’s orientation. General orientation allows NNPs to begin
to understand their new role within the organization. The general-provider orientation is a three-
day meeting that is intended for all the organization’s new providers. At the general orientation,
the providers receive a detailed itinerary with a list of the presenters and topics that are covered
throughout the general orientation. The presenters and topics focused on information about the
organization and introducing new providers to the healthcare organization’s leadership team.
Cohort 1
Overall, all participants felt the general-provider orientation was beneficial, well rounded,
and comprehensive. Two of the six participants expressed feeling overwhelmed during the
orientation due to the amount of information presented in such a short period. The topics
participants found as most beneficial were the review of benefits and the clinical practice
overview. Other high points of orientation were computer training and networking with the
other new providers.
Cohort 2
Cohort 2 participants also felt the general-provider orientation was comprehensive. The
participants felt overwhelmed by the amount of information given over the three days of
28
orientation. The most beneficial part of the orientation included meeting the healthcare
organizations leadership team, networking with new providers, and the review of benefits.
Clinic Orientation
The clinical orientation process was different for each Cohort 1 participant. The
participant’s practice location was intentionally removed to protect anonymity. Clinical
orientation varied widely from no clinical orientation, to “scribing” for or “shadowing” a
provider.
Cohort 1
Participants 1 and 2 could tour their clinic practice location during the general-provider
orientation. These participants had between 8 and 14 patients on their schedule on clinical Day
1. Scheduled patients ranged in age, chief complaint, and the type of visit. Participants
expressed that they felt “unprepared,” “unsupported,” “scared,” “intimated,” “overwhelmed,”
and “stressed” during the clinical orientation.
Participants 3 and 4 oriented as a “scribe” for other providers for the first eight days. As
a “scribe” the participant would follow another provider throughout the day and perform all
EMR tasks including charting, placing consults, and entering orders. On days nine and ten, the
participants would see the patients scheduled to the assigned preceptor. After seeing the patient
the participants were expected to discuss the patient history, exam, and plan of care with their
preceptor. The participants believed their clinic used the “scribe” role to ease the transition to
practice by observing another provider in practice and developing their EMR skills. Starting on
Day 11 each participant was scheduled to see eight patients per day. The scheduled patients
were considered “low-complexity” or scheduled for routine “physical examinations.” The
scheduled patients varied in age, unless the NNP requested not to see a certain age group.
29
Participants 3 and 4 believed the number and type of patients scheduled per day was appropriate
for their level of skill after orientation. Only one of the participants was involved in discussions
regarding when the number of patients scheduled was increased.
The last two participants’ clinical orientation included shadowing a NP, PA, or physician
in the clinic for three weeks and then beginning to see patients independently on week four.
Participants were scheduled four to six patients per day post-orientation. The patient population
consisted of patients under 65 years of age. There were no limitations on the visit reason or the
complexity of patient. One participant felt that some of the patients that were scheduled were
inappropriate for a NNP skill level. “Age has nothing to do with complexity.” “I could see
someone for an acute problem or post hospitalization, but I was not able to be their PCP.” Only
one of the participants was involved in discussions about increasing the number of patients
scheduled.
The relationships and support from the clinic’s staff members varied for the participants
in Cohort 1. All participants had difficulty in identifying whom to contact about clinical
concerns, scheduling, equipment locations, and role development. Four of the six participants
felt they were welcomed and supported by other staff members. Two of the six participants did
not feel welcomed or supported, “The staff expected me to be a proficient provider” and “it
wasn’t very welcoming.”
Cohort 1 participants were not involved in a mentorship program, and “feared” asking
another provider clinical questions. Four of the six participants were assigned a preceptor. All
participants, including those with a preceptor, felt like they were “burdening other providers”
and “did not know who to ask” regarding clinical questions. A common perception found
throughout Cohort 1 was “It is not their [other providers’] responsibility to answer my
30
questions.” Participants did not continue the mentor/mentee relationship once they began
practicing independently.
Cohort 2
All Cohort 2 participants completed the recently established standard orientation process.
The participants practice sites were intentionally omitted to protect participant anonymity.
Participants completed the four phases of orientation in 8 weeks. Once orientation was
completed, the NNPs and their assigned preceptors collaboratively decided on how many
patients, length of visit, and the type of visits that were scheduled. Two of the participants’
initial schedule included physical exams and episodic visits, while the other participant was
scheduled to see walk-in patients with acute problems. All participants felt that their scheduled
patients were appropriate for their skill level. When Cohort 2 participants were practicing
independently, they were scheduled to see six to eight patients per day. Two of the three
participants had increased the number of patients scheduled in collaboration with the clinic’s
leadership team. One participant had just finished orientation and had not yet increased the
number of patients scheduled per day.
All participants reported being introduced to and feeling welcomed by other staff
members on day one and throughout orientation. Participants were made aware of the point of
contact for clinical concerns, scheduling, and equipment early on in their orientation. Two
participants immediately felt that they were part of the team while one participant did not feel
like part of the clinic’s team until one month into the orientation.
Participants felt that the mentorship component built into their orientation and the team-
based care model lessened the burden of asking questions and seeking consult. Participants
denied the fear of asking their preceptor or other providers questions about clinical situations.
31
“We use the team approach, so I am able to talk to anyone in my team if I have any questions.”
Another participant said, “All the other providers have offered availability with my questions or
training needs.” One participant recommended that preceptors should volunteer to precept and
should receive education about the preceptor role and responsibilities prior to serving as a
preceptor.
Clinical Competencies
Clinical competencies include the NNPs’ knowledge and understanding of the primary
care quality measures (PCQM), the credentialing process, and determining scope of practice. In
2016, the Centers for Medicare and Medicaid Services established a core set of PCQMs, which
include:
• Control of high blood pressure.
• Persistent beta-blocker treatment after a heart attack.
• Aspirin or another antithrombotic use in the presence of ischemic vascular disease.
• Comprehensive diabetes care.
• Medication reconciliation.
• Cervical-cancer screening.
• Breast-cancer screening.
• Colorectal-cancer screening.
• Tobacco-use screening and cessation.
• Body-mass-index screening and follow-up.
• The use of imaging studies for low back pain.
• Depression remission at 12 months.
• Medication management for people with asthma.
32
• Avoidance of antibiotic treatment for adults with acute bronchitis.
Of these, participants were not aware that persistent beta-blocker treatment after a heart
attack, medication reconciliation, cervical-cancer screening, tobacco-use screening and cessation,
body-mass-index screening and follow-up, the use of imaging studies for low back pain, and the
avoidance of antibiotic treatment for adults with acute bronchitis were PCQMs (Figure 3).
The healthcare organization has a standardized process for credentialing NNPs clinical
competencies at the start of practice and every two years thereafter. The NNP completes a
general-competency skills sheet to identify the previous skills and competencies. The healthcare
organization Department of Family Medicine Policy on Focused Professional Practice
Evaluation and Department of Internal Medicine (Clinic Based) Policy on Focused Professional
Practice Evaluation, under the supervision of the Office of Professional Practice, outlines
procedural skill validation and credentialing process for NNPs. All participants were considered
Class 2: Recent graduate from a training program at another facility, where the requested
privileges were part of the training program. A pertinent key term defined within the policies is
concurrent proctoring. Concurrent proctoring is defined as “real time observation of a
procedure” within each policy. A brief overview of the healthcare organization’s policy on skills
validation and credentialing for Class 2 NNPs is as follows:
• The provider must demonstrate the requested skill or procedure at least twice in the
presence of a proctor assigned by the department chair.
• The proctor must complete a validation form for each skill demonstration and route
the form to the practitioner and the department chair.
• Upon completion, the department chair will route the validation forms to the Office of
Professional Practice.
33
• The Office of Professional Practice sends the validation forms to the credentialing
committee.
• The credentialing committee either accepts or declines credentialing based on policies
set forth by the healthcare organization.
• The credentialing committee notifies the provider and department chair of the
decision set forth by the committee.
In order for the NNP to be credentialed to perform a specific skill, the NNP must contact the
department chair to begin the process of learning the skill, validating the skill, and discussing
whether there is the need for special training prior to perform the skill independently.
Cohort 1
Cohort 1 participants’ understanding and performance of clinical competencies varied.
All participants understood PCQMs. Although, the only PCQM all participants could recall was
comprehensive diabetes care. Four of the six participants surveyed their personal PCQMs rating
monthly. Three of the six participants learned their PCQMs by receiving a laminated sheet that
identified “theirs,” and were asked to identify ways to improve their PCQMs. Two of the six
participants reviewed their PCQMs daily, knew the PCQMs established threshold, and the
organization’s goal for each PCQM. One participant did not learn about PCQMs during
orientation; however, PCQMs were introduced during their NP education. None of the
participant could name all the PCQMs established by the Centers for Medicare and Medicaid
Services.
Cohort 1 participants could not consistently describe how to have a skill validated or how
to apply to be credentialed for a type of care or procedure. One participant believed the skills he
or she was able to perform in the clinic was based on their “comfort level.” Two participants
34
were told by their preceptor which skills they were able and unable to perform once they had
demonstrated the skill at least once to a provider credentialed for that skill. Three participants
reported completing a “core privileges” document prior to entering practice, and once in practice,
they needed to demonstrate the selected “skills” to a provider to complete the credentialing
process for core privileges.
Cohort 2
The participants in Cohort 2 had a better understanding of their PCQMs and credentialing
process than Cohort 1. Cohort 2 participants assessed their PCQMs “almost daily” by “going on
the intranet at work,” and could name the PCQM measures related to comprehensive diabetes
care, peripheral vascular disease care, and comprehensive asthma care. Cohort 2 participants
reported having discussions with their clinical supervisor about their PCQMs, the clinic’s PCQM
goals, and ways to improve individual PCQMs. Two of the three participants learned about the
PCQMs during clinical orientation. All participants were unable to verbalize the PCQMs
established by the Centers for Medicare and Medicaid Services (Figure 3).
Cohort 2 participants varied in their ability to verbalize how to obtain credentialing in the
clinical setting. One of the three participants did not know what procedures he or she could
perform or how to obtain credentialing to perform procedures. Two of the three participants
remembered that they had received a booklet about skill validation and credentialing at the
general provider orientation.
35
Figure 3. PCQMs identified by participants. The PCQMs that were not identified by either
cohort group were excluded from the figure.
Electronic Medical Record
Cohort 1
All Cohort 1 participants felt that a more effective and efficient EMR training program
was needed early in the clinical orientation. The healthcare organization encourages new
providers to schedule a meeting with the clinic EMR trainer for one-on-one training during their
first week of independent practice. Four of the six participants met with the EMR trainer during
the first week of independent practice, and they felt that the one-on-one training was more
beneficial than any other EMR training they received.
Cohort 2
All participants in Cohort 2 felt their EMR training provided a strong foundation for
efficient navigation of the EMR. All participants felt they gained the most benefit from the one-
on-one training with the EMR trainer. Two of the three participants could complete the one-on-
36
one training with the EMR trainer during the second week of orientation, as scheduled, while the
third participant completed the training during week three due to scheduling conflicts.
37
CHAPTER SIX. DISCUSSION AND CONCLUSION
Orientation is a crucial time in the NNPs transition into a new role and organization. The
orientation process can be a roadmap for new employees to navigate the ins and outs of the
organization. The orientation process should include a system-wide orientation along with a job-
specific orientation. The system-wide orientation or on-boarding should include information
related to “organization and system’s policies, informatics, computer-order entry, safety,
equipment training, employee-identification badge process, office access, completing
credentialing packets, and setting up voicemail” (Yeager, 2010 p. 87). Clinical orientation
should include education about how to “access patient records, enter orders, access dictation
lines, access radiographic informatics, build relationships, observe clinical flow, and acquire
procedural skills” (Yeager, 2010 p.87).
The NNPs’ individual needs and progress ought to dictate the duration of their orientation
to support the NNPs confidence, safety, quality care, and ultimately a successful transition to
practice. Bahouth and Esposito-Herr (2009) suggested that an NNP’s orientation should be at
least 12 weeks in duration. However, even with a 12-week orientation, Bahouth and Esposito-
Herr believed that the NNP do not have the ability to practice proficiently and independently for
at least 1 year of practice.
Both cohorts felt they would get more benefit from a structured orientation process. The
orientation of Cohort 1 participants was less structured and differed by location while Cohort 2
orientation was pre-planned, structured, and comprehensive. Common themes found after
analyzing the interview data were categorized into General-Provider Orientation, Clinic
Orientation, Clinical Competency, and Electronic Medical Record. Organizing the qualitative
data into Cohort similarities and differences was helpful to the author when formulating
38
recommendations to the target healthcare organization about the orientation process for NNP
employees.
General-Provider Orientation
The purpose of the general-provider orientation, Phase 1 of the structured orientation
process, is to welcome new providers to the organization and essentially is the get to know us
component of orientation (Appendix D). The general-provider orientation is a three-day meeting
that is a requirement for all new providers. There is a structured itinerary of speakers and topics
felt to be important for assimilation in to the organization. During general orientation, the
leadership team is introduced to the new providers. Yeager’s (2010) recommended that the
system orientation should occur at the beginning of orientation and should give an overview of
the organization’s policies, informatics, EMR use, safety measures, equipment use, employee-
identification badge process, office access, and other organization specific information. The
general-provider orientation met and exceeded the system orientation recommended by Yeager.
Most participants in both Cohorts had a positive opinion about general-provider
orientation. Areas covered during the general-provider orientation were consistent with Yeager’s
(2010) recommendations of a system-wide education during the initial orientation stages that
NNPs are introduced to the organization’s policies, informatics, EMR, safety measures,
equipment use, employee-identification badge process, and office access. Cohort 1 and 2
participants agreed that the general-provider orientation was comprehensive, yet overwhelming
due to the amount of information received. Both cohorts considered the opportunity to network
with other new providers as most beneficial.
39
Clinic Orientation
The NNP develops their practice, and expand their skills and knowledge during the first
year of practice (Hill & Sawatzky, 2011). The biggest difference in clinical orientation between
Cohort 1 and Cohort 2 was how soon each cohort began seeing patients independently. Cohort 1
did not have a specific orientation plan. Orientation to their new role was via performing as a
scribe for another provider or shadowing a designated provider. Cohort 1 felt they would have
received benefit from an individualized, structured orientation. Cohort 2 had a structured clinical
orientation that included scheduled conversations about the participant’s patient schedule and
clinical performance. Cohort 2 felt as if they received a very comprehensive orientation and felt
confident transitioning to independent practice. Yeager (2010) found a structured orientation
fosters a smoother transition and increases role satisfaction and confidence.
In Cohort 1, two participants worked an additional four hours daily while four
participants worked an added two hours daily once practicing independently to complete clinical
documentation. Cohort 1’s extended hours supports the study conducted by Kelly and Mathews
(2001) finding that many NNPs experienced a loss of control with their time during their
transition into practice, and Hill and Sawatzky’s (2011) findings that NNPs needed more time to
complete clinical tasks. Cohort 1 was unable to complete clinical tasks throughout the day due
to patient scheduling. Hill and Sawatzky (2011) found that NNPs worked longer hours, and had
fewer breaks during the day to meet the healthcare organization’s expectation that the NNP
perform at an experienced NP level. Cohort 2’s participants felt that they had adequate time to
complete clinical tasks throughout the day post-orientation leading to no extended clinical hours.
The questionnaire (Appendix F) used the term mentor whereas the term preceptor was
used in the orientation materials. Often the terms mentor and preceptor are used
40
interchangeably. To eliminate confusion, the term mentor or mentorship will encompass the
terms preceptor or preceptorship. Mentoring is a relationship between a novice and an expert to
promote role socialization and self-efficacy, and ultimately a successful role transition (Hill &
Sawatzky, 2011). Cohort 1 participants did not have an identified mentor like Cohort 2. Four of
the six participants in Cohort 1 and all Cohort 2 participants developed a mentor relationship
with another provider during their transition to practice. However, those mentoring relationships
were not continued after orientation; the exact reason for not continuing the relationship is
unknown. Harrington (2011) found that barriers such as the lack of time, schedule limitations,
space constraints, and lack of organizational support contributed to the discontinuation of
mentoring. Participants in Cohort 2 continued to have a relationship with their mentor beyond
orientation.
Mentorship programs create a supportive environment to fill the transition between
didactic and independent practice (Hill & Sawatzky, 2011). There were questions specific to
collaboration and supportive environment within the interview questionnaire. Cohort 1 would
have liked more input and collaboration with clinic leadership about the number and type of
patients scheduled per day and regular feedback about clinical performance. The “fear”
expressed by Cohort 1 is similar to the study conducted by Hill and Sawatzky (2011) that NNPs
believe they need to practice independently to receive peer support. Yeager’s (2010) study
found that NNPs have feelings of inadequacy and self-doubt. Cohort 2 participants were
comfortable asking other providers clinical questions. Cohort 2 reported all providers in their
clinic were approachable and willing to help answer any clinical and non-clinical questions
supporting the argument by Harrington (2011) and Fitzpatrick and Gripshover (2016) that the
role of a mentor is to guide and counsel NNP during their transition to practice.
41
There was a consistent theme among participants about the value of interprofessional
relationships during orientation and beyond. Most the participants felt they received a friendly
and welcoming response from colleagues and staff. The participants did not face a hostile
environment or critical interprofessional interactions as discussed in several studies (Fitzpatrick
& Gripshover, 2016; Yeager, 2010). The differences between the PIP participants and those
described in the literature may be multifactorial. The reason for the friendly and welcoming
environment might be attributed to traits of residents in the region of the U.S. where the
organization is located. The clinic is located, and the staff lives in the U.S. upper Midwest.
Midwest residents ranked highest on a national poll in extraversion and agreeableness and tended
to be sociable and affable (Rentfrow, Gosling, Jokela, & Potter, 2013). Using a multisampling
approach over 12 years, Rentfrow et al looked at the personality and social characteristics of
612,140 people within three regions in the lower 48 states. Midwesterners were described as
friendly, sociable, considerate, dutiful, and traditional people. Participants used some of the
same terms to describe colleagues, mentors, and clinic personnel.
Bahouth and Esposito-Herr (2009) reported NNPs develop multiple support systems, and
having a positive influence on transition to practice. Four of the six participants in Cohort 1 had
little to no time to develop a support system within the clinic, while all participants in Cohort 2
had eight weeks to develop a support system within the clinic. Four of the six Cohort 1
participants were ambiguous about the roles and responsibilities of each member of the clinical
team, and learned through “trial and error.” All participants in Cohort 2 were aware of the roles
and responsibilities of each member of the clinical team through the interactions that occurred
during their orientation. Both cohorts identified a need to shadow “ancillary staff” within the
clinic during their orientation. Hill and Sawatzky (2011) found that “understanding the clinic’s
42
flow and staff members’ role was essential for the NNPs to understand to how they fit into the
clinical team” (p. 162).
Clinical Competencies
The data-collection tool assessed the participants’ understanding of primary care quality
measures (PCQMs). The Centers for Medicare and Medicaid Services developed and
implemented PCQMs to provide guiding principles that are meaningful to patients, consumers,
and physicians, while reducing variability in measure selection, collection burden, and cost
(Centers for Medicare and Medicaid Services, 2016). The interview questionaire focused on
NNPs’ awareness about PCQMs. Participants in Cohort 1 obtained their PCQM status during a
monthly staff meeting or during a discussion with their clinic’s RN health coach. The healthcare
organization describes the role of the RN health coach as someone who designs, implements, and
maintains health-education programs for communities in order to help prevent the spread of
disease and to promote healthy lifestyles. RN health coaches work with health professionals,
community officials, and others to develop health services. During the implementation phase of
orientation, the healthcare organization added the PCQMs to the intranet home page, and NNPs
could view their PCQMs every time they accessed the intranet. Cohort 2 had greater access to
their PCQM data and participants were able to recall more measures, when asked.
To be eligible to request privileges for a particular practice area, providers must meet the
minimum threshold criteria for privileges set by the employing organization. Threshold criteria
consist of minimum standards for training, experience, licensure, certification, and evidence of
mental and physical status appropriate to the demands of practice. If the minimum threshold
criteria are met, core privileges are granted. The process of granting privileges may differ from
organization to organization. Typically, a credentialing committee decides if privileges are
43
granted, or if the NP needs to provide additional evidence of training and proficiency. Cohort 1
was not aware how to become credentialed for skills and procedures beyond their core
privileges. Two of the three participants in Cohort 2 learned about skill validation and
credentialing from their preceptor, and from a “booklet” given to them during general provider
orientation. The reason for participants’ unfamiliarity with the skill validation and credentialing
process is unclear. Participants were given written information about the credentialing process
during orientation. NNPs may not need to apply for privileges beyond the core privileges.
However, the NNP must be familiar with the core privileges for their area of practice so that they
know when added credentialing is needed and how to obtain the credentials. Including skill
validation and credentialing on the orientation checklist may be one way to assure the topic is
reviewed. According to the participants, they had difficulty finding information about skill
validation and privileges on the organizations intranet. The organization may want to look at
ways to make the information easier to access.
Electronic Medical Record
Barnes (2015a) suggested that prior experience with EMR might be more important for
successful RN to NP transition than previous RN experience. Four of Cohort 1 participants and
all three of Cohort 2 participants had worked for the healthcare organization in the past and were
familiar with EMR. Cohort 1 thought that the EMR training in the general provider orientation
was of no benefit and could be discontinued. Cohort 2 suggested that that the organization could
improve the EMR training during general-provider orientation by separating new providers into
two groups based on prior experience with the EMR.
Many providers create “quick texts” such as preference lists, favorites, templates for
common conditions, and smart phrases to increase their efficiency in using the healthcare
44
organization’s EMR. Time allocated to developing “quick texts” was different between the two
cohorts. Both cohorts learned how to create “quick texts” within the EMR during the general-
provider orientation. Four of six Cohort 1 participants did not develop “quick texts” before
practicing independently due to not knowing the common conditions seen within the clinic.
Ultimately, the participants’ inability to develop “quick texts” decreased their efficiency using
the EMR system, and increased their time to complete clinical documentation. All Cohort 2
participants had time to develop “quick texts” along with observing their mentor’s frequently
used “quick texts.” Cohort 2’s use of “quick texts” may account for not needing added time to
complete clinical documentation.
Both cohorts thought that one-on-one training with the EMR trainer increased their EMR
proficiency and comfort level. Cohort 1 completed one-on-one training by week six of practice,
while Cohort 2 completed EMR training by the fourth week of orientation. Cohort 1 requested
the one-on-one EMR training when they encountered a problem, while Cohort 2 had the EMR
training built into the orientation schedule.
Limitations
The initial intent of the PIP was to develop, implement, and evaluate, an orientation
process for new NP and PA providers starting employment at a healthcare organization. The
advanced practice leadership group’s intent was the creation of a comprehensive, structured, and
consistent orientation for NPs and PAs hired to work in primary care. The initial objective of
this PIP was to assist in the development, implementation, and evaluation of an orientation
program. The focus of the PIP changed when administrators at the healthcare organization
implemented a separate structured orientation process. The focus of the PIP shifted to assisting
the healthcare organization and the advanced practice leaders to compare and evaluate the
45
previous and current orientation process by interviewing NNPs who went through previous
orientation (Cohort 1) and the most recent orientation (Cohort 2).
During the time between Cohort 1 and Cohort 2’s transition to practice, the healthcare
organization also implemented a team-based model of care for its primary-care clinics. The
National Academy of Medicine defined a team-based model of care as
The provision of health services to individuals, families, and/or their communities by at
least two health providers who work collaboratively with patients and their caregivers, to
the extent preferred by each patient, to accomplish shared goals within and across settings
to achieve coordinated, high-quality care. (Schottenfeld et al., 2016, p. 2)
The team leader ensures that all team members contribute their clinical expertise by working to
their highest level of training, experience, and licensure (Schottenfeld et al., 2016). A team-base
care model improves patient and provider satisfaction, expands access to care, increases job
satisfaction, improves employee retention, improves time efficiency, and creates an environment
where all medical and non-medical professionals are encouraged to perform work that matches
their abilities (Schottenfeld et al., 2016). Implementing the team-based care may have enhanced
the mentorship received by the Cohort 2 participants by placing patient panels not on one
provider, but all providers on the clinical team.
There were several limitations associated with this practice improvement project. The
limitations are as follows:
• The small sample size limits the ability of the project to create generalized
recommendations for future orientation processes.
• Participants in Cohort 1 entered practice as a NNP at the organization up to 18
months prior to data collection, which potentiates the participant’s self-reported
46
biases of selective memory, attribution, and exaggeration. Different results may have
been collected from Cohort 1 if the interviews were conducted in the same period
post-orientation as Cohort 2.
• Collecting data in three different interview forms (face-to-face, e-mail, and telephone)
may have changed the data obtained from each cohort. Face-to-face interviews
promote an impromptu response during a period, while the responses from e-mails
allowed the participant to put thought into their answers. Data collected during
telephone conversations could not be reviewed to ensure the participant’s responses
were dictated correctly.
• Data could have been collected from more sources, which includes, but not limited to
clinical peers, clinical leadership, and the EMR. Incorporating multiple avenues of
data collection during a change in orientation provides more data to assess the impact
on the NNP, healthcare organization, and patient experience/outcome.
• The interview questionnaire (Appendix F) was derived from barriers found in the
literature. The questionnaire has not been used in any other studies nor in any other
organizations.
Recommendations
Throughout the data collection, participants in each cohort offered recommendations to
improve their orientation. Recommendations will be made to the healthcare organization based
on participants’ feedback and from the literature. The hope is that the healthcare organization
can use the information to change or improve the orientation process in a way that benefits NNPs
and the healthcare organization. The director of the organization’s education department,
advanced practice provider leadership team, and other members of the organization’s leadership
47
team are recommended to implement the recommendations set forth by the cohorts. Identified
areas of improvement include Phase 1, clinical orientation, credentialing, and the data collection
tool.
The organization may want to review and trim some of the material presented in Phase 1,
general-provider orientation, so that new providers are not so inundated with data and people.
Perhaps some of the information could be taught using different pedagogic methods. For
example, a video recorded message, an interactive electronic module, or even a game like a
scavenger hunt.
NNPs should have an opportunity to shadow team members. Enabling a shadowing
experience of other clinical team members during the orientation process would ensure that all
new NPs learn the roles and responsibilities of all clinical team members throughout the clinic.
In utilizing the structured orientation process, the most effective time to implement a shadowing
experience with other clinical team members would be in the afternoon of day 14. Day 14 is the
transition from department orientation to beginning concurrent visits. On day 14, the NNP
maintains their normal schedule with his/her preceptor in the morning, and shadows the other
clinical team members throughout the afternoon. Clinical team members identified by the
participants are as follows:
• The clinic’s scheduler informs the NNP of the scheduling process, the types of
patients seen within the clinic, and the time allocated for each visit type.
• The lead RN promotes the NNP’s understanding of the roles and responsibilities of
nursing staff, the location of supplies, and the patient flow all while developing
rapport with the nursing staff.
• The RN health coach to learn about their referral process, role, and services provided.
48
Assigning or choosing a consistent preceptor or mentor helps to cultivate the mentoring
relationship that will continue long after orientation finished. The preceptor should know the
roles and responsibilities of a preceptor. The organization could consider having a designated
preceptor for each clinic that is compensated for lost productivity, and is given the time to
precept well.
Education pertaining to skill validation and credentialing is needed not only for NNPs,
but also for all practicing providers. NNPs should be educated on the organization’s policies
pertaining to skill validation and credentialing during Phase 1 of orientation. The credentialing
committee could periodically distribute paper and electronic information on the steps of
credentialing and skill validation, so that all providers have easy access to the information.
The healthcare organization needs to establish a process for the continued evaluation of
the orientation process. The data collection tool (Appendix F) can be used to continue to collect
data on the orientation process. The department leadership can utilize this tool during the first
face-to-face quarterly meeting with the new NP. A question to be included in the data collection
tool is to assess scheduled hours verse actual hours worked.
Implication for Practice
Each year the number of NPs graduating and entering the workforce is growing
exponentially (AANP, 2015), with up to 80% of the new NPs choosing to work in primary care
(Naylor and Kurtzman, 2010). The NNPs provide a sustainable supply of PCPs, which increases
patients’ access to care, especially in rural and underserved areas. The large number of
graduating NPs, and the desperate need for PCPs, creates a good problem for healthcare. NNPs
are stepping-up to meet the primary care provider shortage. In the rush to fill PCP positions, we
49
must not forget about the time and guidance necessary for NNPs to the provider role. The extra
effort will be time well spent.
Healthcare organizations that are willing to invest in a NNPs’ orientation, transition to
practice and role development will benefit from the investment through higher retention rates
and other less tangible costs to replace a provider such as a decreases in patient satisfaction,
quality metrics, and group moral (Heil, Culhane, & Munkner, 2015). Having a well-planned
structured orientation not only familiarizes the NNP with a new environment, but also provides
new learning experiences. A well-planned structured orientation should be personalized and
designed to bridge the education to practice chasm by providing the tools and resources
necessary for a successful transition.
Transitioning from an experienced RN to a practicing NNP can be intimidating and
challenging. According to Hart and Bowen (2016), nearly half (49%) of NNPs felt they were
practicing outside of their competency level during their first year of clinical practice. A well-
planned structured orientation is crucial for the NNP’s successful transition, increased
confidence, and perceived competence. NNPs who transition poorly, experience lower job
satisfaction and feelings of discontentment, contribute to higher turnover rates (Barnes, 2015a).
Due to the limited literature specific to orientation of NNPs entering primary care,
healthcare organizations are attempting to define best practices through “trial and error.”
Educators and healthcare leaders, with input from NNPs, should collectively design an evidence
based comprehensive orientation program to effectively transition the large number of NNPs
entering practice. The literature that identifies orientation best practices for NNPs is sparse and
inconclusive, as also seen in this project.
50
The small sample size, an inconsistent interview process, and inconsistent orientation
experience between and within cohorts limited the applicability of the data to other
organizations. At this particular healthcare organization, the small sample of NNPs preferred the
structured orientation to ‘no orientation’, scribing, and or shadowing experiences. Participants
discovered that having a scheduled time with a preceptor or mentor improved communication,
improved time management, fostered mentoring that continued beyond orientation, and provided
a better understanding of the roles and responsibilities of an NP. Additionally, scheduling one-
one-one EMR training increased NNPs EMR efficiency and proficiency, allowing for more time
away from the clinic.
Conclusion
Healthcare organization, in collaboration with educators, and NNPs must begin to
research and develop best practices for NNP transition from expert to novice to expert again.
The best approach to successful transition is yet to be discovered. A well-planned, structured
orientation process provides a roadmap for NNPs to navigate new role acquisition, develop
interprofessional relationships, enhance job satisfaction, and establish mentorship relationships.
A well-planned and structured orientation bridges the gap between education and practice by
fostering a smoother transition to practice. One healthcare organization recognized the need for
a better orientation and implemented that orientation allowed evaluation through this PIP and
will make changes of improvements that benefit the NNP, the organization, the clinical team,
and ultimately the patient.
51
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56
APPENDIX A. PERMISSION TO USE BENNER’S “NOVICE TO EXPERT” NURSING
THEORY IMAGE
From: Coble, Richard <[email protected]> and McDaniel, Rhett
Sent: Monday, February, 13, 2017 7:53 AM
To: Czapiewski, Dustin <[email protected]>
Subject: Permission for use of images
Dear Dustin,
Thank you for this email. I am fine with your using the image, as long as you document it
properly.
However, I would ask that you also receive permission from Rhett McDaniel (cc'd here),
Educational Technologist at Vanderbilt's Center for Teaching. He was the one who developed
the image after I wrote the guide.
All the best with your research.
Richard
Richard Coble
Religion, Psychology and Culture Graduand
Theology and Practice Fellow
57
Dear Dustin,
Certainly. Everything on the CFT site is offered as Creative Commons. It would be nice
to site the source as Vanderbilt Center for Teaching.
Rhett McDaniel
Educational Technologist | Center for Teaching
Vanderbilt University
1114 19th Avenue South, 3rd. Floor
P: 615-322-3424
F: 615-343-8111
58
APPENDIX B. PERMISSION TO USE THE REPEATED PDSA CYCLE
From: Salvador, Melina <[email protected]>
Sent: Monday, February, 13, 2017 10:38 AM
To: Czapiewski, Dustin <[email protected]>
Subject: Permission for use of images
Hi Dustin,
We are thrilled that you have found our resources useful. Please feel free to use the image in
your presentation. We just ask that you cite the website if only to increase access.
Please let me know if you have any other questions.
Best,
Melina
Melina Salvador, MA
Research Associate
James Bell Associates, Inc.
3033 Wilson Blvd. Suite 650
Arlington VA 22201
Phone: 505.990.9052
59
APPENDIX C. NDSU IRB APPROVAL
60
APPENDIX D. GENERAL-PROVIDER ORIENTATION SAMPLE SCHEDULE
(INSERT NAME, EMPLOYEE #, SPECIALTY & LOCATION HERE)
(Insert dates here)
(If hotel reservation, enter info here – place address, confirmation #)
Day 1
8:45 am Meet organization representative in the main lobby
9:00 – 9:30 am Professional Photo
9:30 – 10:00 am Employment Paperwork
10:00 – 10:30 am Compensation
10:30 – 11:15 am Benefits
11:15 – 11:30 am Radiology
11:30 – 11:45 am Lab
11:45 – 12:45 pm Welcome Lunch with Directors, Vice Presidents, and Department
Chairs
1:00 – 2:00 pm Intro to Computer Applications
2:00 – 4:00 pm EMR Training
Day 2
8:00 – 9:00 am Coding
9:00 – 9:30 am Meaningful Use
9:30 – 10:00 am Medication Management/Pharmacy
10:00 – 11:00 am Communication/Professionalism
11:00 – 11:30 am Break
11:30 – 11:45 am Utilization Management
11:45 – 12:00 pm Infection Control
12:00 – 1:00 pm Lunch with Disclosure/Risk Management
1:00 – 1:15 pm Health Information Management
1:15 – 2:00 pm Break
2:00 – 4:00 pm EMR Training
Day 3
8:00 – 9:00 am Breakfast with Administration
9:00 – 9:15 am Media & Marketing
9:15 – 10:00 am Cultural Diversity
10:00 – 10:30 am Corporate Compliance
10:30 – 10:45 am Public Affairs
10:45 – 11:15 am Quality
11:15 – 11:45 am Welcome to the organization
11:45 – 12:30 pm Lunch on your own
12:30 – 4:30 pm EMR Training
61
APPENDIX E. STRUCTURED ORIENTATION PROCESS
Objective: The objective of the orientation plan is to orient and prepare the NNP to function in
their assigned role at the completion of the plan.
• The plan includes didactic and clinical training provided by the staff and supervising
physicians. Progress reviews are built into the plan for ongoing communication and
evaluation.
• The orientation plan is concluded through mutual agreement of the individual and clinical
team.
• The plan generally occurs in four phases over a period of four to eight weeks, which may
vary based upon individual training and experience.
Primary Preceptor: (Director/Department Chair to assign)
Phase 1: General Orientation:
Park on the top floor of the parking deck located north of the main hospital.
Day 1-4: This is general-provider orientation. A detailed itinerary will be provided by the
medical staff office.
Phase 2: Department Orientation: (Days 4 – End of week 2)
Day 4: 1 pm: Meet with (Director/Clinical Supervisor) Welcome & Introduction.
___Introduction to clinical team
___Review clinic workflow
___Scheduling template
___Tour
___Department norms (parking, time sheet, vacation requests, ill calls, call schedules etc.)
62
Day 5 –End of week 2: 0800-1700 Observe practice (Define specifically who they will shadow
by day). NNP to set up documentation templates, smart phrases
Example:
Friday, March 25th
8:00am-12:00 pm: Shadow physician or NNP
12:00 pm – 1:00 pm: department welcome lunch
1:00 pm-4:00 pm: Shadow physician or NNP
4:00 pm– 5:00 pm: set up documentation templates, smart phrases
Phase 3: Begin Concurrent Visits: (Week 3-4)
Week 3: Begin concurrent clinic visits where the NNP performs and documents the entire visit
under the direct supervision of the preceptor. Continue to build smart phrases.
Week 4: Schedule NNP 60 minute visits. Schedule CI Ops/HAT to work with NNP. CI
Ops/HAT should be scheduled for 1 hour during week 5. Review at the end of week four with
preceptor. Determine schedule for following week. Consider increasing schedule to 45 minute
visits of normal template for the following week. If appropriate proceed to Phase 4.
Week 5: Begin concurrent hospital rounds/visits where the NNP performs and documents the
entire visit under the supervision of the preceptor if applicable. Review at the end of week five.
If appropriate proceed to Phase 4.
Week 6: Schedule NNP at least 45 minute visits. Review at the end of week six with preceptor.
Determine schedule for following week. Consider increasing schedule to 30-minute visits of
normal template for the following week. If appropriate, proceed to Phase 4.
63
Week 8: Schedule NNP at least 30 minute visits. Review at the end of week eight with
preceptor. Determine schedule for following week. Consider increasing schedule 75% visits of
normal template for the following week. If appropriate, proceed to Phase 4.
Phase 4: Conclusion of Orientation
Conclusion of orientation and complete the NNPs Patient Schedule. This would be determined at
the conclusion of Phase 3, and would be done in collaboration with members of the team. It is
anticipated this would occur at the end of 3 to 8 weeks depending on experience.
Other:
(Date/time) At one month after the NNP has been seeing patients, schedule a 1:1 meeting with
the department coder and NNP to review documentation and LOS.
(Date/time) 30-day check in with Director/Clinical Supervisor. Schedule follow up resource
meetings as needed.
(Date/time) 60-day check in with Director/Clinical Supervisor.
(Date/time) 90-day check in with Department Chair/VP.
(Date/time) At three month after the NNP has been seeing patients, schedule a 1:1 meeting with
the department coder and preceptor to review documentation and LOS.
(Date/time) quarterly check in with Director/Department Chair/VP for first year in practice.
64
APPENDIX F. NOVICE NURSE PRACTITIONER INTERVIEW QUESTIONAIRE
Demographics:
Gender: Male Female Age:
Status: Full-Time (≥ 0.8 FTE) Part-Time (<0.8 FTE)
Years as practitioner (in months):
Specialty: Family Medicine Internal Medicine
Have you worked at Sanford Health in the past? Yes No
Are you new to this role in Sanford Health? Yes No
Have you worked in the clinic where you are practicing
before entering the role you are currently in? Yes No
General-Provider Orientation:
1. Was the general-provider orientation / Phase one comprehensive, and was pertinent material
discussed? What was most/least beneficial part of this orientation?
2. How was the training / education in policies, benefits, EMR training, and procedural skills?
3. Is there anything you would have like added / removed during this part of the orientation?
Clinical Orientation:
1. Is there a current orientation process in the clinic, and if not, would one be of benefit?
2. Were you introduced to other staff members and informed of point of contacts with practice
and clinical concerns? Were you supported and welcomed as a new team member upon
entering practice?
3. How did you learn your roles and responsibilities?
4. Is there a mentoring program, if so did you participate in it?
5. Is there other provider available to ask questions, and why did you chose those providers?
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6. Are you aware of the quality indicators in your practice? If so, what are they? How did you
learn about your quality indicators? How frequently do you asses and evaluated on your
quality indicators? How do you plan to improve your quality indicators in the future?
Practice Specifics:
1. What type of patients were you assigned after your orientation? Were you involved in this
decision? How did you feel about seeing the type of patient’s you were assigned?
2. How many patients were you expected to see per day after your orientation? Were you
involved in this decision? How would you like to see your patient load increase to reach a
full load?
3. How long were patients scheduled after your orientation? Were you involved in this
decision? How did you feel about seeing patient’s during the scheduled time?
4. Was utilizing the organizations electronic medical record user friendly to ensure you
maintain a balance between time with the patient and time for documenting the visit? What
would you consider was the most difficult part of utilizing the organization’s electronic
medical record?
Preceptor specifics:
1. Did you have an opportunity to work with or shadow other clinical members prior to seeing
patients independently? With whom and how long? Would this be beneficial prior to
entering practice?
Educational Preparation
1. Are you aware of what procedural skills you can perform in the clinic? What are they?
What is the process of obtaining and maintaining credentials to perform the skills you may
perform in the clinic?
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APPENDIX G. EMAILED INVITATION AND INFORMED CONSENT
NDSU North Dakota State University
Department of Nursing
Campus Address
NDSU Dept. 2670
PO Box 6050
Fargo, ND 58108-6050
701.231.8995
Title of Research Study: Enhancing the Orientation Process for Nurse Practitioners
Entering Primary Care
Greetings nurse practitioners:
My name is Dustin Czapiewski. I am a graduate student in the doctor of nursing practice
program at North Dakota State University (NDSU), and I am conducting a research project to
improve the novice nurse practitioner (NNP) orientation process in primary care at Sanford
Health. With this research, we will learn more about the current orientation process for novice
nurse practitioners entering the primary care setting. The goal is to evaluate previous orientation
processes, and assist in the development an orientation process that can be individualized for
NNPs in primary care clinical setting at Sanford Health.
Because you are nurse practitioner who entered the primary care setting at Sanford
Health within the past two years, you are invited to participate in this research project. You will
be one of approximately 10 people being interviewed for this study.
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You may find it interesting and thought provoking to participate in the interview. If,
however, you feel uncomfortable in any way during the interview session, you have the right to
decline to answer any question(s), or to end the interview.
It should take about 30 minutes to complete the interview. You will be asked about
demographics, NNP perceptions of general and department specific orientation, and perceptions
of ease of transition to practice. The interview will be audio recorded, and transcribed by the
researcher. All research records that may identify you will be kept private. When the interview
is transcribed, you will be given a pseudonym, and other potentially identifying information will
be left out of the transcripts. In any written documents (including publications) regarding the
study, only the pseudonym will be used.
Audio files will be stored in a password-protected file on a computer that is only
accessible to the principal investigator and co-investigators. Electronic copies of the interview
transcripts will be saved and protected in the same fashion. After the data has been analyzed, the
audio recordings will be deleted.
If you have any questions about the study, please contact me at 701-261-8756 or
[email protected], or contact my advisor at Dr. Tina Lundeen, 701-231-7747 or
You have rights as a research participant. If you have questions about your rights or
complaints about this research, you may talk to the researcher or contact the NDSU Human
Research Protection Program at 701.231.8995, toll-free at 1-855-800-6717, by email at
[email protected], or by mail at: NDSU HRPP Office, NDSU Dept. 4000, P.O. Box 6050,
Fargo, ND 58108-6050.
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Thank you for your taking part in this research. If you wish to receive a copy of the results,
please notify me at [email protected].
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APPENDIX H. EXECUTIVE SUMMARY
Background and Significance
Novice nurse practitioners (NNPs) face many challenges when transitioning to practice,
which include, but are not limited to, time management, interprofessional relationships, role
ambiguity, transition shock, inconsistent onboarding, and lack of mentorship. The process of
transitioning from an experienced registered nurse (RN) to a NNP creates role ambiguity, self-
doubt, and feelings of inadequacy (Yeager, 2010). A structured orientation is shown to be more
beneficial than previous RN experience. A structured orientation fosters a smoother transition,
increases role satisfaction, retention, and confidence. When healthcare organizations are able to
anticipate and minimize barriers, they increase the likelihood that NNPs experience a seamless
and successful transition.
Project Summary
A well-planned and structured orientation should meet the needs of NNPs with and
without familiarity with the organization’s operations. The purpose of this project was to
evaluate the orientation process at a healthcare institution. Using a plan-do-study-act (PDSA)
model the orientation process was evaluated, barriers identified, and recommendations made to
the organization. Two cohorts of NNPs were interviewed. Cohort 1 worked at the healthcare
organization for 12-18 months, while Cohort 2 worked at the healthcare organization for 1-5
months. Both cohorts had the same general orientation; however, Cohort 2 had a more
structured clinical orientation.
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Common Themes
General-Provider Orientation
The majority of the participants in both Cohorts had a positive opinion about general-
provider orientation. Areas covered during the general-provider orientation were consistent with
Yeager’s (2010) recommendations of a system-wide education during the initial orientation
stages that NNPs are introduced to the organization’s policies, informatics, EMR, safety
measures, equipment use, employee-identification badge process, and office access. Cohort 1
and 2 agreed the general-provider orientation was overwhelming and comprehensive; yet
provided an opportunity to network with other new providers.
Clinic Orientation
The biggest difference in clinical orientation between Cohort 1 and Cohort 2 was how
soon each cohort began seeing patients independently. Cohort 1 did not participate in a
structured clinical orientation. Orientation to their new role was via performing as a scribe for
another provider or shadowing a designated provider. Cohort 1 felt they would have benefitted
from an individualized, structured orientation. Cohort 2 had a structured clinical orientation that
included scheduled conversations about patient schedule and clinical performance. Cohort 2 felt
as if they received a very comprehensive orientation and felt confident transitioning to
independent practice.
In Cohort 1, two participants worked an additional four hours daily while four
participants worked an additional two hours daily once practicing independently to complete
clinical documentation. Cohort 1’s extended hours supports Kelly and Mathews (2001) study
finding that many NNPs experience a loss of control with their time during their transition into
practice, and Hill and Sawatzky (2011) findings that NNPs need more time to complete clinical
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tasks and meet the healthcare organization’s expectations. Cohort 1 was unable to complete
clinical tasks throughout the day due to patient scheduling. Cohort 2’s participants felt that they
had adequate time to complete clinical tasks throughout the day post-orientation.
The data collection tool used the term mentor whereas the term preceptor was used in the
orientation materials. Often the terms mentor and preceptor are used interchangeably. To
eliminate confusion, the term mentor or mentorship will encompass the terms preceptor or
preceptorship. Cohort 1 participants did not have an identified mentor like Cohort 2. Four of the
six participant in Cohort 1 and all Cohort 2 participants developed a mentor relationship with
another provider during their transition to practice. The relationships formed in Cohort 1 ceased
at the completion of the orientation process, which may be due to the barriers identified by
Harrington (2011) of time, schedule limitations, space constraints, or organizational support.
The PIP was unable to capture the indication from the participants on why the relationships
between their mentors ceased at the end of the orientation process. All participants in Cohort 2
continued their mentoring relationship beyond orientation.
Assessing the NNPs perception of collaborating with other providers is how the project’s
questionnaire obtained data addressing the presence or absence of a supportive environment.
Cohort 1 wanted to collaborate with clinic leadership about the number and type of patients
scheduled per day and to get feedback about their clinical performance. The “fear” expressed by
Cohort 1 may support Hill and Sawatzky (2011) findings that NNPs think they need to practice
independently in order to obtain their peers’ respect or Yeager (2010) findings of NNPs feeling
inadequate and experiencing self-doubt. Cohort 2 participants were comfortable asking other
providers clinical questions. Cohort 2 reported all providers in their clinic were approachable
and willing to help answer any clinical and non-clinical questions supporting Harrington (2011)
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and Fitzpatrick and Gripshover (2016) roles of a mentor is to guide and counsel NNP during
their transition to practice.
There was a consistent theme among participants about the value of interprofessional
relationships during orientation and beyond. The majority of the participants felt they received a
friendly and welcoming response from colleagues and staff. The participants did not face a
hostile environment or critical interprofessional interactions as discussed in several studies
(Fitzpatrick & Gripshover, 2016; Yeager, 2010). The difference between the PIP participants
and those described in the literature may be multifactorial. The cause for the friendly and
welcoming environment could be attributed to organizations location. The healthcare
organization and clinic staff live in the U.S. upper Midwest. Midwest residents ranked highest
on a national poll in extraversion and agreeableness and tend to be sociable and affable
(Rentfrow, Gosling, & Potter, 2008). Perhaps the clinical team wanted to start the relationship
on a positive note, leading the team to better deal with stressful situations in the future (Yeager,
2010).
Bahouth and Esposito-Herr (2009) reported NNPs develop multiple support systems, and
having a positive influence on transition to practice. Four of the six participants in Cohort 1 had
little to no time to develop a support system within the clinic, while all participants in Cohort 2
had eight weeks to develop a support system within the clinic. Four of the six Cohort 1
participants were ambiguous about the roles and responsibilities of each member of the clinical
team, and learned through “trial and error.” All participants in Cohort 2 were aware of the roles
and responsibilities of each member of the clinical team through the interactions that occurred
during their orientation. Both cohorts identified a need to shadow “ancillary staff” within the
clinic during their orientation. Hill and Sawatzky (2011) found that “understanding the clinic’s
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flow and staff members’ role was essential for the NNPs to understand to how they fit into the
clinical team” (p. 162).
Clinical Competencies
The data-collection tool assessed the participants’ awareness about primary care quality
measures (PCQMs). Participants in Cohort 1 obtained their PCQM status during a monthly staff
meeting or during a discussion with their clinic’s RN health coach. During the implementation
phase of orientation, the healthcare organization added the PCQMs to the intranet home page,
and NNPs could view their PCQMs every time they accessed the intranet. Cohort 2 had greater
access to their PCQM data and participants were able to recall more measures, when asked.
To be eligible to request privileges for a particular practice area, providers must meet the
minimum threshold criteria for privileges set by the employing organization. Threshold criteria
consist of minimum standards for training, experience, licensure, certification, and evidence of
mental and physical status appropriate to the demands of practice. If the minimum threshold
criteria are met, core privileges are granted. The process of granting additional privileges may
differ from organization to organization. Typically, a credentialing committee decides if
privileges are granted, or if the NP needs to provide additional evidence of training and
proficiency. Cohort 1 was not aware how to obtain additional skill validation and credentialing,
and incorrectly reported the healthcare organization’s skills credentialing process. In contrast,
two of the three participants in Cohort 2 were aware how to obtain skill validation and
credentialing, and correctly report the credentialing process. The Cohort 2 participants attained
this information from their preceptor, and from a “booklet” given to them during clinical
orientation.
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Reasons for the lack of knowledge about skill validation and credentialing included a
multitude of factors. The cause of the uncertainty about skill validation and credentialing for six
of the nine participants may have occurred because the participants in neither cohort had the
opportunity to perform skills during their orientation. The participants’ clinic may utilize few to
no procedural skills, causing the participants to be unaware of the validation and credentialing
process. Information addressing skills credentialing is difficult to find and confusing in the
organizations Department of Professional Practice intranet share-point.
Electronic Medical Record
Barnes (2015a) suggested that prior experience with EMR might be more important for
successful RN to NP transition than previous RN experience. The majority of Cohort 1 familiar
with EMR use received no benefit from EMR training during general-provider orientation. All
participants in Cohort 2 expressed benefit from the EMR training during the general-provider
orientation due to separating new providers into two groups based on prior experience with EMR
use, which did not occur in Cohort 1
Time allocated to developing “quick texts” was different between the two cohorts. Both
cohorts learned how to create “quick texts” within the EMR during the general-provider
orientation. Four of six Cohort 1 participants did not develop “quick texts” before practicing
independently due to not knowing the common conditions seen within the clinic. Ultimately, the
participants’ inability to develop “quick texts” decreased their efficiency using the EMR system,
and increased their time to complete clinical documentation. All Cohort 2 participants had time
to develop “quick texts” along with observing their mentor’s frequently used “quick texts.”
Cohort 2’s utilization of “quick texts” may account for not needing additional time to complete
clinical documentation.
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Both cohorts thought that one-on-one training with the EMR trainer increased their EMR
proficiency and comfort level. Cohort 1 completed one-on-one training by week six of practice,
while Cohort 2 completed EMR training by the fourth week of orientation. Cohort 1 requested
the one-on-one EMR training when they encountered a problem, whereas Cohort 2 had the EMR
training built into the orientation schedule.
Recommendations
Common themes identified through the participant's recommendations and the data
collected formulate the recommendations presented to the healthcare organization. It is believed
that implementing recommendations proposed by the participants, will improve the transition to
practice within this healthcare organization. Phase 1 needs to be reviewed in the amount and
type of information being presented to new NPs. Less pertinent information should be
disseminated in the form of a PowerPoint or computer module, which the new NP can review
during Phase 2. The Cohorts requested shadowing experiences with the clinic’s scheduler, lead
RN, and RN health coach. Implementation of a consistent preceptor who is informed of their
roles and responsibilities. The implementation of education on skill validation and credentialing
during Phase 1, and during the clinic’s monthly provider meeting. The continued evaluation of
the orientation process through the department leadership team utilizing the data collection tool
during the first face-to-face quarterly meeting with the new NP.
